Applicant Information

Full Name *

Street Address *

Apartment/Unit #

City *

ZIP Code *

Phone *

Email *

Which medical specialty you are interested in? Please rank your top four (4) choices:

Which County would you prefer to rotate? Please rank all three (3) choices in order of preference. (subject to availability)

What are you looking to gain from this experience? *

1000

Reflecting on your experience with physicians AS A PATIENT (or perhaps the experience of someone close to you), what have you learned about what makes a good doctor? *

1000

What does diversity in medicine mean to you? How do you think your identity and lived experience will play a role in your future career? *

1000

Education

High School

From

Address

College

From

Address

Medical School

From

Address

References

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to approval of externship, I understand that false or misleading information in my application may result in externship cancelation.

Signature

Date

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